Sp706 Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction

Abstract

Expanding Indication: EUS-Guided Hepaticoduodenostomy in Isolated Right Intrahepatic Duct Obstruction Se Jeong Park*, Do Hyun Park, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim After failed ERCP, other alternative biliary accesses such as PTBD, repeated ERCP, or surgical bypass could be considered. PTBD has a complication rate of 10% to 30% such as bile leak, bleeding, and peritonitis. Repeat ERCP could be as an alternative if immediate biliary drainage is not required. Surgical bypass is effective, but is associated with considerable mortality and morbidity. EUSguided transgastric imaging of dilated left intrahepatic duct is a useful technique to drain the left biliary system and an effective alternative for percutaneous transhepatic biliary drainage after failed ERCP. To date, EUS-guided biliary drainage in isolated right hepatic duct obstruction has not been attempted. In our center, 4 consecutive patients were candidates for EUS-guided right hepatic duct approach within recent year with last case in October 2012. We performed three kinds of approaches to the right hepatic duct using EUS; (1) using a cholangiogram obtained by EUS-guided transduodenal puncture of the right hepatic duct as a “roadmap” to assist retrograde cannulation, (2) EUS-guided transduodenal puncture of the right hepatic duct and an antegrade balloon dilatation and stenting for bilioenteric anastomotic strictures in a patient with hepaticojejunostomy, and (3) transluminal stenting as an antegrade bypass stenting between the right hepatic duct and the duodenal wall under EUSguidance. EUS-guided hepaticoduodenostomry (EUS-HD) of right hepatic duct by expert hands may be a relatively safe and feasible alternatives after failed ERCP. Moreover, an availability in the same session without dicontinuation of sedation after failed ERCP is another great advantage. In contrast, the other alternative accesses such as PTBD, repeated ERCP, and surgery almost need another session for further procedure on a different day. Further, large multicentered study may help enhance our results.